Healthcare Provider Details

I. General information

NPI: 1083309504
Provider Name (Legal Business Name): NICOLE CHRISTINE SANDRUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE CHRISTINE MATELITE

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7629 BELAIR RD
NOTTINGHAM MD
21236-4003
US

IV. Provider business mailing address

8200 EVERGREEN DR
BALTIMORE MD
21234-5509
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-2104
  • Fax:
Mailing address:
  • Phone: 443-529-6434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29443
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: